It just goes against every grain of my coding background to code based off a positive lab test when that is the only thing the patient came in for. Yes it was ordered by the provider but I am literally coding Covid for just a positive lab test...no provider documentation to go with that test. I can't do that with a lab only visit for a positive flu test...are you following me??
The guidelines I have are actually attempting to do the opposite of what you are suggesting - and override the "Uncertain Diagnosis" section of the guidelines that have been around a while (that are intended to support what a Doctor thinks the patient has vs just what test results may say). In the latest publication, they are saying just because a doctor says "probable" Covid - do NOT code it as Covid, only code it if they CONFIRM DIAGNOSIS. Otherwise just code the symptoms.
I think what you are asking about is the first sentence: "as documented by the provider or documentation of a positive COVID- 19 test result." The "OR" in that sentence suggests that you can code on provider documentation OR just the test result. But the paragraph says TWICE "code only a confirmed diagnosis", and goes onto say - NOT if they say probable. Which for all other diseases (except Covid, Zika, HIV and Acute respiratory failure) you should code "Probable" as having the disease.
It would seem to me that someone has told you to code on the Lab result only - perhaps incorrectly? (Basing this off coding guide FY 2021 – UPDATED January 1, 2021, perhaps there is a newer version? )
Relevant Sections of ICD-10-CM pasted below:
Section II H:
Uncertain Diagnosis
If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.
Section 1, C 1 g 1 (a)
g. Coronavirus infections
1) COVID-19 infection (infection due to SARS-CoV-2)
(a) Code only confirmed cases
Code only a confirmed diagnosis of the 2019 novel coronavirus disease (COVID-19) as documented by the provider or documentation of a positive COVID- 19 test result. For a confirmed diagnosis, assign code U07.1, COVID-19. This is an exception to the hospital inpatient guideline Section II, H. In this context, “confirmation” does not require documentation of a positive test result for COVID19; the provider’s documentation that the individual has COVID-19 is sufficient. If the provider documents "suspected," "possible," "probable," or “inconclusive” COVID-19, do not assign code U07.1. Instead, code the signs and symptoms reported. See guideline I.C.1.g.1.g.
